扩张型心肌病临床与预后的关系探讨

目的 :探讨扩张型心肌病(DCM )发生心脏性猝死 (SCD)的高危因素 ,研究DCM临床与预后的关系。方法 :对 60例DCM临床资料进行分析 ,以超声心动图 (UCG)、心电图 (ECG)、动态心电图 (DCG、Holter)及X线胸片观察心脏各参数变化 ,并做心电图QT离散度 (QTd)测定。结果 :有病毒性心肌炎病史与无病毒性心肌炎病史病人 ,重度心力衰竭、严重室性心律失常的发生率分别为 66.7%和 2 3 .3 % ,经比较有统计学意义 (P <0 .0 5 ) ;5例SCD均有病毒性心肌炎史 ,临死前都发生多次严重室性心律失常、晕厥 ;QTd对预测SCD高危因素有意义。结论 :有病毒性心肌炎史、心力衰竭、严重室性心律失常、头晕或晕厥及QTd增加 ,可作为预测发生SCD的高危因素。     

埋藏式心脏复律除颤器在肥厚型心肌病心脏性猝死高危患者一级预防中的临床疗效分析

目的:总结分析国内肥厚型心肌病(HCM)心脏性猝死(SCD)高危患者一级预防植入埋藏式心脏复律除颤器(ICD)的有效性和安全性。方法:连续入选2011年1月至2017年12月在阜外医院植入ICD作为一级预防的HCM SCD高危患者,对ICD恰当治疗、不恰当治疗及ICD植入相关并发症进行回顾性分析。结果:共纳入38例HCM SCD高危患者,平均年龄(52.1±16.3)岁,其中男性25例(65.8%)。平均随访(29.3±24.2)个月,14例(36.8%)患者接受≥1次的ICD恰当治疗,ICD恰当治疗率为13.3%/年。多因素COX回归分析显示,SCD家族史(HR=11.8,95%CI:1.3～107.5,P=0.029)为ICD恰当治疗的独立预测因子。随访期间4例(10.5%)患者接受ICD不恰当治疗。2例(5.3%)患者发生ICD植入相关并发症,随访期间无死亡事件发生。结论:HCM SCD高危患者一级预防植入ICD恰当治疗率高,ICD不恰当治疗率和植入相关并发症发生率低,SCD家族史是ICD恰当治疗的独立预测因子。     

心脏四部位起搏的临床应用一例

评价四部位心脏起搏治疗充血性心力衰竭室内传导阻滞和房性快速心律失常的疗效。结果 :右室心尖部、右室流出道、右房、冠状窦左房的起搏阈值分别为 0 .6,0 .5 ,0 .4,0 .8V ;阻抗为 80 0 ,488,63 2 ,5 5 2ohm。右室双部位起搏阈值 1.0V。二尖瓣返流减轻 ,射血分数提高 40 %,心功能改善到Ⅱ级 ,未见房性快速心律失常发生。结论 :心脏四部位起搏是治疗充血性心力衰竭室内传导阻滞并房性快速心律失常的有效方法     

致心律失常性右心室心肌病临床诊断探讨

目的探讨致心律失常性右心室心肌病的临床诊断标准.方法将19例致心律失常性右心室心肌病患者常规行超声心动图、心电图、X线胸片、24小时动态心电图、心房调搏及心内电生理检查.结果本组19例患者均有心悸,晕厥发作,心电图多为右束支传导阻滞(78.95%),频发室性早搏(89.5%),右心室源性短阵室性心动过速(78.95%),超声心动图右心室50.80±9.88?mm,右心房48.00±8.79?mm,均增大,右心功能减退,射血分数0.294±0.0812.结论致心律失常性右心室心肌病,可根据发作性晕厥,右束支传导阻滞,频发室性早搏及左束支传导阻滞型室性心动过速,右心室、右心房增大,右心室功能减退,并排除其他各类心脏和胸肺疾病后确诊.     

高钾血症引起心律失常34例临床分析

目的分析高钾血症引起心律失常的特点.方法回顾性总结分析34例高钾血症患者引起心律失常的情况.结果窦性心动过缓17例(占50%),Ⅰ度房室传导阻滞(Ⅰ°AVB)9例(占26.5%),Ⅱ度房室传导阻滞(Ⅱ°AVB)2例(占5.9%),房颤转为窦性心律2例(占5.9%),窦室传导7例(占20.6%),室性早搏1例,室扑室颤2例.采用综合抗高血钾治疗32例心律失常得以纠正(占94.1%).2例患者进行了临时心脏起搏治疗.血钾轻度升高的同时伴有低血钙及低血钠3例患者发生了窦室传导.结论高钾血症引起心律失常多为缓慢性心律失常,阿托品治疗无效,心内膜起搏治疗起搏阈值增高;引起的心律失常与低血钠和(或)低血钙明显有关.高血钾可使心房纤颤转为窦性心律.     

心肌病猝死高危患者无创预警参数分析

目的:探讨心肌病猝死高危患者中有预测价值的无创性指标。方法:回顾性分析410例心肌病住院患者的恶性心律失常[室性心动过速(VT)或心室颤动(VF)]发生率及左室射血分数(LVEF),并随访调查心源性猝死(SCD)的发生情况。测量其中心电图记录清晰的200例患者(心肌病组)的心电图参数QRS时限、QT间期和Tp-Te间期,计算QTc。取80例健康者作为心电图参数对照组,比较2组QTc分布情况。根据QRS时限将上述200例患者分为QRS≥120ms(75例)和QRS<120ms(125例)。根据LVEF值将410例患者分为30%≤LVEF≤35%(207例),35%50%(18例)。分别对无创性指标LVEF、QTc、Tp-Te、QRS与VT/VF、SCD发生的关系进行分析。结果:410例中,245例(59.8%)发生心律失常,其中心房颤动102例(24.9%),VT/VF 54例(13.2%),Ⅰ度房室传导阻滞15例(3.7%),Ⅱ～Ⅲ度房室传导阻滞15例(3.7%),其余并发房性期前收缩或室性期前收缩共59例(14.4%)。心肌病组中QTc≥460ms者所占比例明显高于对照组(22.0%:7.5%,P<0.01);Tp-Te与QTc呈正相关(P=0.009);QRS≥120ms者的SCD发生率比QRS<120ms者明显增加(32.0%:18.4%,P<0.05)。随着LVEF降低,SCD发生率有增高趋势,但均差异无统计学意义。结论:高度房室传导阻滞、VT/VF是心肌病高发SCD的常见原因。QTc≥460ms和Tp-Te延长、QRS≥120ms是预测心肌病患者SCD发生的有效参数;LVEF可能具有预测心肌病患者发生VT/VF的潜在价值。     

冠心病猝死的相关因素分析

目的探讨冠心病患者心脏性猝死的发生率及其相关因素。方法回顾分析46例冠心病患者住院期间发生心脏性猝死的有关临床资料,男性32例,女性14例,年龄38-83（49．5±10．7）岁。收集患者的诱因、心电图（ECG）、超声心动图、动态心电图、X线胸片、心电监护、电解质等资料,根据患者相关项目逐项进行分析。结果46例猝死患者占同期冠心病总住院数的2．2％。多数发生猝死的冠心病患者存在一定高危因素,电解质紊乱、Lown3-5级室早、高度房室传导阻滞、束支传导阻滞、心脏扩大、左室肥厚、心功能不全、持续心肌缺血等因素均可触发致命性心律失常;猝死起始的ECG类型及其演变过程多有一定规律性。结论冠心病患者的心脏性猝死发生率为2．2％。冠心病患者发生猝死与电解质紊乱、Lown3-5级室早、高度房室传导阻滞、束支传导阻滞、心脏扩大、左室肥厚、心功能不全、持续心肌缺血等高危因素密切相关。有效控制危险因素能大大降低冠心病猝死发生率。     

QRS波时限对起搏器依赖患者心脏功能的影响

目的:观察右心室起搏QRS波时限对起搏器依赖患者心脏功能的影响。方法:选取在我院诊断为Ⅲ度房室传导阻滞并行永久性右心室起搏的患者112例,以起搏QRS波时限将患者分为A组(起搏QRS波时限<190ms)和B组(起搏QRS波时限≥190ms),并对每例患者进行临床评估和心脏彩色多普勒超声检查,动态随访心脏功能,以随访期间出现明显心功能下降为终点,观察起搏QRS波时限与心脏功能的关系。同时根据随访期间是否出现心功能下降将患者分为心功能下降组(Y组)和心功能无下降组(N组),并进行各因素与心功能下降之间的单因素分析,取P<0.1的因素纳入Logistic回归模型,寻找影响起搏器依赖患者心功能的因素。结果:平均随访(45.46±23.00)个月,40例(28.57%)出现明显心功能下降,其中,A组24例(27.27%),B组16例(66.67%),2组间差异有统计学意义(P=0.0004),Y组的起搏QRS波时限较N组明显延长[(176.58±22.71)∶(159.74±20.23)ms,P<0.0001]。多元Logistic逐步回归分析结果显示,左心室舒张末期内径增大、射血分数下降、左束支传导阻滞、起搏QRS波时限≥190ms、年龄及起搏时间是起搏器依赖患者心功能下降的危险因素。结论:起搏QRS波时限延长是心脏功能下降和心力衰竭发生的危险因素,可以作为起搏器依赖患者起搏后心脏功能下降的预测指标。除此之外,左心室增大、左束支传导阻滞、射血分数降低、年龄及起搏时间也是起搏器依赖患者心脏功能下降的危险因素。     

肥厚型心肌病猝死预警的新指标:合并J波(122)

正肥厚型心肌病(HCM)既有明显的遗传倾向,又是一个典型的高交感性心血管病,这些使其发生心脏性猝死(SCD)的几率高,因此寻找与发现HCM猝死的预警指标一直是热点话题。目前已有5个预警指标:(1)非持续性室速;(2)心室极度肥厚≥30mm;(3)不明原因晕厥;(4)SCD家族史;(5)运动中有血压异常反应。2017年美国三大学会的专家共识推荐,当HCM患者伴有上述5个危险因素之一时,则应植入ICD进行SCD的一级预防。     

序贯起搏治疗急性缓慢型心律失常23例分析

对于急诊常见的缓慢型心律失常，如高度房室传导阻滞，常导致晕厥、阿斯综合征甚至猝死，临床常用药物和心脏起搏的方法治疗．有创的心脏起搏疗效比较确切。但南于该操作相对比较复杂、专科性强、操作时间较长，在急诊抢救治疗中受到一定限制。而经皮临时心脏起搏操作方便快速，可作为有创起搏的保护性治疗手段，与有创起搏治疗序贯进行。我院近年利用序贯起搏技术治疗缓慢型心律失常患者，疗效显著，现报道如下。     

Alcohol septal ablation versus surgical septal myectomy: comparison of effects on atrioventricular conduction tissue

OBJECTIVES: This study was designed to evaluate the effect of septal reduction therapies on the conduction system for patients with hypertrophic cardiomyopathy (HCM). BACKGROUND: Heart block is a potential complication of both catheter-based and surgical procedures to relieve left ventricular outflow tract obstruction in HCM, but it is important to understand the different effects of these treatments on the conduction system. METHODS: The electrocardiograms and postoperative course of patients who underwent percutaneous alcohol septal ablation or surgical myectomy at Mayo Clinic between 1999 and 2003 were reviewed. RESULTS: For the 58 patients who underwent alcohol septal ablation, 21 (36%) developed right bundle branch block. Six patients (12%) developed complete heart block requiring permanent pacing, three of whom had left bundle branch block before the procedure. Among the 117 patients who underwent surgical septal myectomy, 47 (40%) developed left bundle branch block. Four patients (3%) developed heart block requiring permanent pacing after the procedure, three of whom had right bundle branch block preoperatively. CONCLUSIONS: Percutaneous septal ablation selectively produces transmural infarction of the basal mid-septum and adjacent right bundle tissue, whereas surgical myectomy affects the endocardial portion of the basal anterior septum and adjacent left bundle tissue. These observations may help identify patients at risk for complete heart block after septal reduction procedures for HCM.     

肥厚型心肌病QT离散度及其与左室重量关系的研究

目的　观察肥厚型心肌病 (HCM )患者QT离散度 (QTd)与左室重量 (LVM)关系 ,探讨HCM患者心室肌复极电活动稳定性及引起其不稳定的主要原因。方法　HCM患者 6 4例 ;梗阻组 (HOCM ) 33人 ;非梗阻组 (HNCM ) 31例 ;对照组健康人 32例。三组均做 12导联同步心电图及超声心动图。测定三组QTd、心率校正的QT离散度 (QTcd)、舒张期左室内径 (LVEDD) ,舒张期室间隔厚度 (IVST)及左室后壁厚度 (LVPWT) ,计算出LVM。结果　①HCM组 (包括HOCM组和HNCM组 )LVM、IVST、QTd、QTcd较正常对照组显著提高 (P <0 0 5 ) ;HOCM组与HNCM组上述指标无统计学差别(P >0 0 5 ) ;②HCM患者QTd与LVM呈正相关 ,r为 0 32 5 ;③HCM患者QTd与IVST呈正相关 ,r为 0 4 6 3。结论　HCM患者心室肌复极电活动有着不稳定性及不同步性 ,具有很强的心律失常易感性和心律失常源性 ,可能与左室肥厚的程度 ,重量的增加有关 ,与LVOT有无梗阻无关。     

Prolongation of the averaged QRS complex. A simple prognostic factor in patients with post-infarction bundle branch block and a history of syncope

Patients with a history of myocardial infarction and complete bundle branch block with syncopal episodes have a high risk of sudden death: the identification of the cause of the syncope is therefore essential. The aim of the study was to assess the diagnostic value of non-invasive techniques used in the investigations of syncope: 24 hour Holter recording, high amplification ECG and measurement of left ventricular ejection fraction. The results of these investigations were compared with those of complete electrophysiological investigation evaluating atrioventricular conduction and the inducibility of tachycardia. The patient population was 134 patients, 83 with right bundle branch block and 51 with left bundle branch block. Ninety one patients had inducible sustained ventricular tachycardia and 24 had atrioventricular conduction defects: of these, 14 also had ventricular tachycardia. During follow-up, there were 12 sudden deaths and 13 deaths from cardiac failure. Uni- and multivariate analysis showed induction of ventricular tachycardia to be a significant risk factor for global mortality and sudden death but prolongation of the averaged QRS complex (> 165 msec) was also an independent risk factor of global cardiac mortality. The authors conclude that simple prolongation of the averaged QRS duration > 160 ms in patients with right bundle branch block and > 170 ms in patients with left bundle branch block after myocardial infarction and syncope is a significant poor prognostic factor. However, this sign is not predictive of sudden death.     

Significance of complete left bundle branch block with left axis deviation.

Left axis deviation occurring with complete left bundle branch block may represent divisional left anterior hemiblock in addition to predivisional left bundle branch block. To study this possibility the electrocardiograms of 84 patients with left bundle branch block, in whom previous electrocardiograms were available, were reviewed. There were 49 patients with left bundle branch block and left axis deviation (greater than ? 30 °) (group A) and 35 patients with left bundle branch block and normal frontal axis (group B). The mean age, QRS interval and time Interval between the first and the qualifying electrocardiogram were similar in both groups. The $\text{male}\text{female}$ ratio was significantly different (P < 0.05) and was 26:23 in group A and 9:26 in group B. In group A 24 of 49 patients had a prior electrocardiogram without bundle branch block; in 10 of 24 the pattern indicated hemiblock. Among patients in group B 25 of 35 had a previous electrocardiogram without bundle branch block; a hemiblock pattern was present in only 3 of the 25 (P < 0.05). Seven of 49 patients in group A had a previous electrocardiogram showing left bundle branch block alone whereas 9 of 35 patients in group B had a previous pattern of left bundle branch block. In these seven patients in group A left axis deviation subsequently developed but did not occur in the nine patients In group B. It is concluded that the majority of patients with a left bundle branch block pattern and left axis deviation have left anterior hemiblock separately (either before or after the appearance of left bundle branch block).     

肥厚型梗阻性心肌病经皮腔内室间隔消融术对心电图及自主神经功能的影响

目的观察肥厚型梗阻性心肌病（HOCM）经皮腔内室间隔消融术（PTSMA）对心电图及自主神经功能的影响。方法1998年1月至2003年10月26例患者[男15例,女11例,平均年龄（37．4±11．2）岁]经心脏超声检查诊断为HOCM,在我院行PTSMA,术前3天、术后3天、术后3年分别行体表12导联心电图、24h动态心电图检查,分析PR间期、传导阻滞情况、QRS时限、QT、QT离散度（QTd）、校正QT离散度（QTcd）、JT间期、JT离散度（JTd）、校正JT离散度（JTcd）及心率变异性（HRV）相关指标：RR间期标准差（SDNN）、RR间期平均值标准差（SDANN）、相邻RR间期差均方根（rMSSD）、相邻RR间期差值超过50ms的心搏数占RR间期总心搏数的百分比（PNN50）、低频功率（LF）、高频功率（HF）、LF／HF比值。结果所有患者均成功行PTSMA,1例患者术后出现三度房室传导阻滞并植入永久起搏器,PR间期术后3天显著延长,术后3年恢复正常;术后3天所有患者均表现右束支传导阻滞,术后3年仍有24例患者为右束支传导阻滞;QRS时限、QT间期术后3天、3年均明显延长;QTd、QTcd术后3天明显延长,术后3年恢复至术前水平;JT、JTd、JTcd术后3天、3年均无明显变化;LF、HF、rMSSD、PNN50术后3天、术后3年均较术前明显增加,而LF／HF比值、SDNN、SDANN术后3天、术后3年无明显变化。结论PTSMA治疗HOCM是一种安全有效的方法,术后心电图主要改变为右束支传导阻滞,术后短期QTd、QTcd明显延长,对中远期的心电学参数无明显影响,其可能通过增高迷走神经张力而改善HOCM患者自主神经功能。     

Right bundle branch block: electrocardiographic and prognostic features

The electrocardiographic appearances and the significance of right bundle branch block were described at the beginning of the 20th century. Typical appearances include prolongation > 0.12 s of the QRS complex, RR' or rR' or Rr' appearances in V1 and widened S waves in the leads exploring the left ventricle (SI, aVL, V5 and V6). A delay in the appearance of the intrinsic deflection > 0.08 s may also be observed in the right precordial leads and negative T waves with ST depression may be seen in V1 and sometimes in V2. Left axis deviation of the QRS complex greater than - 45 degrees suggests associated left anterior hemiblock. Right axis deviation beyond + 120 degrees is equivocal. The principal differential ECG diagnosis is the Brugada syndrome, a familial arrhythmogenic autosomal dominant cardiomyopathy of variable penetration. This diagnosis is suggested when ECG abnormalities are observed in patients with a personal or family history of sudden death. Right bundle branch block only seems to have haemodynamic consequences in cardiac failure with associated asynchrony of the left ventricle or in certain cases of right ventricular dilatation encountered in congenital heart disease. The prognosis of right bundle branch block in the absence of underlying cardiac disease is good but it may be poor in other cases, particularly coronary artery disease. Moreover, the prognosis of right bundle branch block to complete atrioventricular block is rare in the absence of associated cardiac disease.     

Influence of right bundle branch block on short- and long-term survival after acute anterior myocardial infarction

The impact of right bundle branch block on long-term prognosis after anterior wall myocardial infarction is unclear. In 932 patients with Q wave anterior infarction, the short- and long-term prognostic significance of the presence of right bundle branch block was analyzed. Compared with 754 patients without block, 178 patients with right bundle branch block after myocardial infarction showed an increased incidence of left ventricular failure (72% versus 52%, p less than 0.001) and increased in-hospital (32% versus 8%, p less than 0.001) and 1 year after hospital discharge (17% versus 7%, p less than 0.001) cardiac mortality rates. The presence of right bundle branch block was an independent predictor of increased in-hospital and 1-year mortality when entered in a multivariate analysis. However, the absence of left ventricular failure identified a subgroup of patients with right bundle branch block with low in-hospital (4%) and 1 year postdischarge (5%) cardiac mortality rates comparable with those of patients with neither failure nor right bundle branch block (1.7% and 4.8%, respectively). In the presence of left ventricular failure, patients with associated right bundle branch block had higher in-hospital (43% versus 14%, p less than 0.01) and 1 year postdischarge (24% versus 9%, p less than 0.01) cardiac mortality rates than those of patients with failure but no right bundle branch block. Thus, the presence of right bundle branch block after anterior myocardial infarction is an independent marker of poor prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

ECG Features that suggest a potentially life-threatening arrhythmia as the cause for syncope

Syncope is a risk factor for sudden cardiac death (SCD) in many conditions associated with structural heart disease as well as inherited heart disease. The ECG in patients with syncope should be examined carefully for signs of structural heart disease, such as myocardial infarction or cardiomyopathy; signs of conduction system disease, such as bundle branch block or atrioventricular block; and signs of primary electrical disease. Important forms of cardiomyopathy accompanied by ECG changes include hypertrophic cardiomyopathy (HCM), and arrhythmogenic right ventricular dysplasia (ARVD/C). Common ECG findings in HCM include left ventricular hypertrophy by voltage, repolarization abnormalities, QRS widening, pseudoinfarction patterns, and slurred QRS upstroke mimicking delta waves. Classical ECG findings of ARVD/C include T-wave inversions and epsilon waves in the right precordial leads (V₁–V₃). Important forms of primary electrical disease which may result in syncope include Wolff–Parkinson–White syndrome, long QT syndrome, and Brugada syndrome, which is characterized by coved ST-segments in the right precordial leads, associated with a history of syncope, ventricular arrhythmia, or sudden cardiac death in probands or family member. There are three Brugada ECG patterns; however, only type I (spontaneous or induced) is considered diagnostic. Recently, studies have suggested that patients with J-point elevation or early repolarization pattern on ECG are at elevated risk of SCD. The clinical significance of finding early repolarization in a patient with syncope is unknown and should be a subject of future research.